Failure to Prevent Accident Hazards Related to Smoking Paraphernalia
Summary
The facility failed to provide adequate supervision and prevent accident hazards by allowing multiple residents to possess unauthorized lighters, despite a policy prohibiting such items in resident rooms. Five residents were found to have lighters in their possession, and staff interviews revealed that there was no written procedure for handling smoking paraphernalia. Staff often handed lighters to residents during smoke breaks and did not consistently retrieve them afterward, resulting in residents retaining lighters in their rooms. Several staff members and residents confirmed that lighters were not always collected after use, and there was a general lack of clarity and enforcement regarding the facility's smoking policy and procedures. One resident, a female with a history of traumatic amputation, dementia, and diabetes, suffered second-degree burns to her right foot after using a lighter to burn a gauze bandage that was too tight. The resident had previously been assessed as safe to smoke unsupervised, with no cognitive impairment noted on her BIMS assessment. On the night of the incident, the resident requested assistance with her bandage, but staff response was delayed. During this time, the resident attempted to remove the bandage herself using a lighter, which resulted in the bandage and her foot catching fire. Staff responded to the fire, and emergency services were called, but the resident initially refused treatment. Interviews with staff and residents indicated that the facility's policy prohibiting lighters in resident rooms was not consistently followed. Staff admitted to not always retrieving lighters after smoke breaks, and residents reported frequently having lighters in their possession. The facility did not have a written smoking procedure, and staff were unclear about the process for supervising residents during smoke breaks and managing smoking paraphernalia. The lack of adherence to policy and absence of clear procedures directly contributed to the incident and the presence of accident hazards in the facility.
Removal Plan
- Resident was sent to the emergency department for assessment after initially refusing any treatment; placed on 1:1 observation; psychiatric services referral made.
- All other residents who smoke, including those discovered with cigarette lighters, had a skin assessment completed with no visible signs of injury related to cigarettes or lighters.
- Facility administrator, director of nurses, and regional compliance swept all resident rooms for items not allowed in resident's rooms and to check for cigarette lighters; removed offending items and completed a log of items found and removed.
- Facility administrator/DON/Compliance nurse will keep a log of any medications/items (including cigarette lighters) not allowed found at bedside during champion rounds; any items discovered will be reported to the DON/Administrator at the time of discovery.
- Regional Compliance Nurse in-serviced the DON and administrator on items not allowed; if a resident is found with a cigarette lighter, the item is to be removed from the room.
- Smoke breaks are to be supervised by facility staff assigned to scheduled smoke breaks; residents will not be given a lighter to keep during smoke break; staff will light the cigarette for the resident and return the lighter to the smoking lock box after use.
- A log will be placed in the lock box to verify the count of cigarette lighters at the start and end of the smoke break; facility staff education provided on the new process.
- Facility administrator, director of nursing, or compliance nurse will review the lighter log for discrepancies.
- Staff were given a copy of the new process and verbal checks by DON and compliance nurses are being conducted each shift to verify understanding.
- Regional Compliance Nurse educated the DON/Administrator that this incident and any other incident related to smoking paraphernalia (including cigarette lighters) to be reviewed monthly by the QAPI committee; Area Director of Operations or Regional Compliance Nurse will attend QAPI committee meetings and verify continued compliance.
- Nursing staff education was begun by the Director of Nurses to ask residents returning from being out of facility to smoke if they have cigarette lighters in possession; if found, re-educate and take items or return them to family; incidents to be reported to DON/Admin immediately.
- Facility staff have been given written fact sheets to keep with them during the learning process and verbal questioning is being done of three staff members at least 5 times weekly and PRN.
- Facility completed education/notification in form of an email to all RPs of residents with a list of items not allowed in residents rooms (including cigarette lighters) and the smoking policy; physical copy to be mailed out to resident RPs; for all future residents, list of items not allowed in room will be provided upon admission as part of the admission packet.
- Education/in-service begun for all staff by facility director of nursing to reiterate the policy of items not allowed in residents rooms (including cigarette lighters) and smoking policy, by phone, COVR, and in person; staff will not be able to return to work until education has been provided; signature or acknowledgement of this education will be confirmed by an audit list; monitored for continuous compliance including new hires.
- Facility provided a copy of list of items not allowed (including cigarette lighters) and the smoking policy to residents and kept a signed copy; residents unable to sign confirmed by two witnesses; signed copy scanned into resident's electronic medical record.
- A sign was placed at the front door of the facility with the items not allowed (including cigarette lighters) and the smoking policy for reference and education.
- The physical environment of all residents was observed (closet, nightstands, storage containers) to ensure no cigarette lighters were retained in their room by the facility administrator, director of nurses, and regional compliance nurse.
- MD was notified of IJ F689 Free of Accidents/Hazards/Supervision/Devices.
- All facility staff were educated by the director of nursing that no residents may be left alone on the smoking patio; staff are to light the resident cigarettes and return lighter to the receptacle for safe keeping; facility administrator will review the lighter logs for compliance.
- All in-service education will be completed by new hires at orientation and before assuming duties in the facility; verified by Administrator, Director of Nurses, or Regional Compliance Nurse.
- Facility department heads or weekend manager on duty will conduct champion rounds in every resident room and look for items not allowed per written company guidelines (including cigarette lighters); remove items if identified and report to DON/Administrator; monitoring to start.
- Regional Compliance Nurse will monitor during weekly visits and ask DON and Administrator what items are not allowed in residents room (including cigarette lighters) and what to do if any are identified; will be questioned about the smoking policy and any identified violations; monitoring to continue for at least 8 weeks and PRN thereafter.
- Administrator/DON will assess five resident rooms for posted items not allowed (including cigarette lighters), to ensure residents do not have any items not allowed in room.
- Regional Compliance Nurse will assess for compliance with posted items not allowed (including cigarette lighters) once weekly by verification of completion of facility assigned monitoring and visual verification of five rooms each week; monitoring to continue for at least 8 weeks and PRN thereafter.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to ensure effective fall alarms and supervision: two residents had Smart Caregiver monitoring devices set to LOW volume, and one resident's bed alarm did not alert staff before the resident was found on the floor after an unwitnessed fall. One resident had dementia, osteoporosis, prior TIA, and cognitive impairment and was fully dependent on staff, while staff also found that a second resident's bed and recliner alarms did not activate properly during testing.
Failure to assess the safety of perimeter mattresses for two residents. Both residents had severely impaired cognition and significant mobility limitations, and both care plans included use of a perimeter mattress to define the edges of the bed. However, their Mobility, Physical Device, and Fall Risk assessments lacked documentation of a perimeter/defined edge mattress assessment. Staff interviews showed inconsistent understanding of the required order, IDT review, engineering review, and safety assessment before use.
Improper Mechanical Lift Transfers: A resident with dementia, spinal cord dysfunction, and dependence for transfers was supposed to be moved with a full-body mechanical lift and two staff members, but a TMA stated she transferred the resident alone. The resident reported that staff sometimes used only one person for lift transfers because of staffing shortages, while other staff and the DON stated this was unsafe and against policy.
Two residents were involved in accident-hazard deficiencies. One resident with cancer, PVD, and Alzheimer’s disease was observed in a wheelchair with feet extending past short footrests, with the lower legs resting against the hard footrests despite a care plan entry for padding. Another resident with dementia and a hx of falls had an unwitnessed fall, but ordered orthostatic BP monitoring was not completed accurately and staff reported no post-fall PT referral was received.
A resident was given a new electric wheelchair without a prior therapy assessment and could not stop the chair, causing it to strike a bed frame and resulting in a leg laceration, tibia/fibula fractures, and a syncopal episode from blood loss. Another resident with cognitive impairment and high fall risk continued to self-transfer and fall, but the care plan was not updated with new fall interventions after repeated incidents.
A CNA used a Hoyer lift alone to weigh one resident, and another CNA was observed using a Hoyer lift alone to weigh a second resident. One resident’s care plan called for a 2-assist Hoyer lift, and the facility’s lift competency checklist and policy both required two caregivers for mechanical lift use; the DON and Director of Therapy also stated that two staff members are always required.
Failure to Ensure Effective Fall Alarms and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and effective use of assistive fall-prevention devices for two residents who were reviewed for fall precautions. One resident had diagnoses including unspecified dementia, age-related osteoporosis, a history of transient ischemic attack, and cognitive impairment, and was described by the POA as weak, bedbound, and unable to participate in physical therapy after a prior right femur fracture. The resident was completely dependent on staff for eating, hygiene, mobility, and toileting, and the care plan included a bed alarm per orders. The resident was found on the floor next to the bed after an unwitnessed fall. The POA reported receiving a call from the facility that the resident had been found on the floor and was not injured, and stated the resident frequently forgot to ask for help and had tried to get up without assistance before. A nurse stated the bed alarm was not heard when the resident fell, and the facility was unable to provide evidence that the bed alarm functioned as intended or alerted staff before the resident was found on the floor. The event report identified the fall as unwitnessed and did not indicate that a bed alarm alerted staff. The facility also failed to ensure the Smart Caregiver sensor pad monitoring system used for another resident was functioning properly and set at an audible volume. Two Smart Caregiver monitor boxes at the nurses' station for that resident's bed and recliner were observed set to LOW volume, and the chime settings faced the back wall of the desk. When a CNA tested the recliner alarm from the resident's room, the monitor at the nurses' station did not illuminate or sound an alert on either attempt. The CNA changed the batteries but did not retest the device, and both CNAs stated they could hear alarms only if they were near the nurses' station and did not recall training on operation or testing of the devices. The facility director stated the facility did not perform preventive maintenance on the devices and relied on staff to ensure they functioned properly.
Failure to Assess Safety of Perimeter Mattresses
Penalty
Summary
The facility failed to ensure that 2 residents with perimeter mattresses were assessed for safety. One resident had a significant change MDS showing severely impaired cognition, dementia, reduced mobility, muscle weakness, and need for assistance with bed mobility, sitting, standing, and transfers. That resident’s care plan identified limited physical mobility related to dementia with mood disturbance and anxiety, a genetic muscle disorder, spinal stenosis, and osteoarthritis, and included use of a perimeter mattress to help find the edges of the bed for bed mobility. However, the resident’s Mobility, Physical Device, and Fall Risk assessment lacked documentation of an assessment for a perimeter/defined edge mattress. The second resident’s annual MDS showed severely impaired cognition, dementia, multiple sclerosis, repeated falls, and need for partial to moderate assistance with bed mobility. The care plan identified limited physical mobility related to weakness, falls, incontinence, hypertension, renal disease, dementia, MS, depression, and delusional disorder, and included use of a bariatric sized bed with a perimeter mattress to define the edges of the bed. That resident’s Mobility Physical Device and Fall Risk assessment also lacked documentation of an assessment for a perimeter/defined edge mattress. During observation, the resident was in bed asleep with a perimeter mattress. Staff interviews showed differing understanding of whether a physician order, assessment, IDT review, engineering review, and safety assessment were required before use of a perimeter mattress, and the DON confirmed both residents’ most recent assessments lacked documentation of a perimeter/defined edge mattress assessment.
Improper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure transfers were performed according to R24’s assessed needs, care plan interventions, and facility policy. R24’s records showed she had diagnoses including non-traumatic spinal cord dysfunction, diabetes, dementia, depression, heart failure, and asthma. She was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had care plan directions for assistance with transfers using a full-body mechanical lift and two staff members. During interviews, a TMA stated she transferred R24 with the full-body mechanical lift by herself because R24 needed to use the bathroom and she felt the transfer was safe. R24 stated staff sometimes transferred her with only one staff member and said they told her there was not enough staff. Other staff interviewed stated transfers with the full-body mechanical lift using one staff member were unsafe and should not occur. The facility policy for using a mechanical lift stated that at least two trained associates are needed to safely move a resident with a mechanical full-body floor-based lift or ceiling/overhead full-body lift.
Unsafe Wheelchair Fit and Incomplete Post-Fall Monitoring
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. Resident 27 was readmitted with diagnoses including cancer, peripheral vascular disease, and Alzheimer's disease and was sometimes able to make needs known. On multiple observations, Resident 27 was seated in a slightly tilted back wheelchair with feet extending beyond the footrests, and the back of the lower legs rested against the hard footrests above the ankle/heel area. A pillow was observed either on the floor or behind the legs rather than padding the footrests. The focused care plan for skin integrity included padding to wheelchair footrests, and staff interviews confirmed the footrests were too short and needed adjustment or replacement, but staff had not notified therapy or otherwise addressed the wheelchair fit. Resident 50 was admitted with diagnoses including dementia, history of falls, and UTI and was sometimes able to make needs known. The care plan identified the resident as at risk for falls. After an unwitnessed fall in the 300 hallway, the incident investigation added interventions to monitor orthostatic blood pressures and refer to physical therapy. However, the record showed an orthostatic blood pressure order on 05/20/2026 was not completed, and subsequent orthostatic blood pressures recorded the same blood pressure and pulse for all three positions on 05/22/2026, 05/23/2026, and 05/24/2026. Staff later stated they had not received a post-fall therapy referral, and the DNS stated the resident should have had orthostatic blood pressures taken accurately to rule out orthostatic hypotension.
Failure to assess electric wheelchair use and update fall interventions
Penalty
Summary
The facility failed to comprehensively assess a resident for the use of an electric wheelchair and failed to develop new interventions to reduce fall risk for another resident. The report states that the facility’s policies required a device evaluation before an electric wheelchair was initiated, resident education and consent, and an updated service plan identifying device use and other interventions. The fall management policy required individualized care plan updates, a systematic review after each fall, identification of root cause, and review of prior interventions when new interventions were implemented. Resident 73 was admitted with weakness and lymphedema and had an above-the-knee left leg amputation, requiring assistance with bed mobility, transfers, and locomotion. The resident’s record showed cognitive intactness, lower extremity impairment, supervision or touch assistance for bed-to-chair transfers, and use of a manual wheelchair. On 4/17/26, a newly issued electric wheelchair was delivered and the resident was assisted into it. The resident reported that the representative showed how the chair worked but not enough, and that the resident did not know how to stop it. The resident then returned to the room, could not stop the chair, and the chair continued forward into the bed, causing the resident’s right leg to strike the metal bed frame. The resident sustained a five-centimeter laceration to the right anterior lower leg, fractures of the right tibia and fibula, and a brief syncopal episode secondary to blood loss. The resident also received an anticoagulant, which contributed to significant bleeding. The clinical record contained no evidence that the resident had been assessed to safely operate the electric wheelchair before use. Resident 3 was admitted with a right total hip replacement with deep hardware removal and post-traumatic osteoarthritis of the right hip. The resident had a high fall risk on Morse Fall Scale assessments, cognitive impairment on OT evaluation, and a PT evaluation showing a score of zero on the Short Physical Performance Battery, indicating high fall risk and increased risk of mobility disability. The resident fell on 3/31/26 after getting up independently and sustained a right femur fracture requiring surgical repair, and fell again on 5/12/26 after getting up independently and sustained a skin tear to the right elbow. The care plan identified fall risk and included reminders to use the call light, non-skid socks, and one-person assistance for toileting and transfers, but revisions to the care plan did not add new or amended fall prevention interventions. Staff statements indicated the resident continued to self-transfer and toilet without assistance, staff believed the resident was independent, and the existing fall prevention interventions were ineffective.
Unsafe One-Person Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure safe use of a mechanical lift for 2 of 3 residents reviewed for accidents. During an observation on 6/2/2026 at 8:42 AM, Resident #4 was lying on his bed on top of a Hoyer pad while CNA Staff K stood on the right side of the bed with a mechanical lift; the lift hand bags were observed over the resident, and no other staff member was in the room. Staff K stated that he was weighing Resident #4 and that normally only one person uses the Hoyer lift for weights, although the resident’s care plan documented a Hoyer lift with 2 assist. On 6/4/2026 at 10:15 AM, CNA Staff D was observed using a Hoyer lift alone to obtain Resident #13’s weight, with the resident lifted approximately 12 inches off the mattress in the sling and no other staff present. Staff D stated that he was performing weekly weights and most of the time did the weights using the Hoyer lift by himself. Resident #13’s MDS Section GG coded the resident as dependent, and the facility’s mechanical lift competency checklist stated that two caregivers are present, while the facility policy for using a mechanical lifting device stated that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The DON and Director of Therapy both stated that a mechanical lift should always be used by two staff members.
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